Exhibits

Which of the following findings should the nurse prioritize?

Thick green mucus

Lung sounds

The tracheostomy state

Fraction of inspired oxygen

None

Answer and Explanation

The Correct Answer is B

Rationale:
A. Thick green mucus is important because it indicates infection and airway secretion buildup. However, while it signals the presence of pneumonia, it is not the most urgent finding to prioritize over immediate respiratory assessment. The nurse should monitor secretions and provide interventions like suctioning or hydration to help mobilize them.

B. Lung sounds are the priority. Diminished lung sounds in the right lower lobe indicate impaired ventilation and potential respiratory compromise due to pneumonia and pleural effusion. Assessing lung sounds helps the nurse determine the severity of the condition and guides urgent interventions such as oxygen therapy, suctioning, or notifying the provider for possible advanced treatment. This directly affects gas exchange and patient safety, making it the most critical finding.

C. The tracheostomy state is important for airway patency. While it must be monitored to ensure it remains patent and functional, the current notes indicate it is in place and functioning normally. Immediate intervention is not indicated unless changes occur.

D. Fraction of inspired oxygen (FiO2) is relevant to oxygen delivery. The client is currently on her usual 30% FiO2, which is appropriate for her baseline oxygenation needs. No adjustment is required unless hypoxia or respiratory distress is noted.

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Correct Answer is A

Explanation

Rationale:
A. Measure pulse and blood pressure: Vital signs are the most immediate indicators of hypovolemia. A rapid pulse and hypotension can signal significant blood loss or inadequate circulating volume, allowing the nurse to detect early shock and initiate prompt interventions.

B. Observe skin elasticity: Skin turgor can provide information about fluid status, but it changes more slowly and is less sensitive than vital signs in detecting acute hypovolemia. It is supplementary to more direct hemodynamic assessments.

C. Measure urine output: Urine output is an important measure of perfusion and renal response to hypovolemia, but it reflects fluid status over a longer period and is not as immediately responsive as blood pressure and pulse.

D. Auscultate breath sounds: While monitoring for pulmonary complications is important after thoracic surgery, breath sounds do not provide direct or immediate information about circulating blood volume or hypovolemic status.

A. Reassess the client every 2 hours. B. Implement seizure precautions. C. Perform a Mini-Mental State Exam (MMSE). D. Elevate head of bed to high Fowler's.

Correct Answer is A

Explanation

Rationale:
A. Reassess the client every 2 hours: The client is currently stable with intact neurological function, but head injuries can deteriorate rapidly. Regular reassessment every 2 hours allows early detection of changes in mental status, motor function, or vital signs, which is essential for timely intervention.

B. Implement seizure precautions: Seizure precautions are indicated if the client shows signs of seizure activity or has a history of post-traumatic seizures. Since the client is alert and exhibits normal neurological function, immediate seizure precautions are not the first priority.

C. Perform a Mini-Mental State Exam (MMSE): While an MMSE can provide a baseline cognitive assessment, it is not necessary as the next immediate action in a stable, alert client. Routine neurological monitoring takes priority over formal cognitive testing.

D. Elevate head of bed to high Fowler’s: Elevating the head of the bed can affect intracranial pressure. For head-injured clients, the head is typically elevated to 30 degrees, not high Fowler’s, to optimize cerebral perfusion while minimizing ICP. This intervention is not the immediate next step for a neurologically stable client.

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Exhibits Which of the following findings should the nurse prioritize?

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Naxlex Comprehensive Predictor Exams

A client returns from surgery following a thoracic aneurysm repair and the nurse plans to observe for signs of hypovolemia. Which assessment should the nurse complete first?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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Exhibits

Which of the following findings should the nurse prioritize?